Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 4 - NSS > Dermatology > Flashcards

Dermatology Flashcards

1
Q

Fitzpatrick Skin Types

A

Fitzpatrick Skin Types

  1. White
    - Never tans
  2. White
    - Usually burns
  3. White
    - Sometimes burns
  4. Moderate brown
    - Rarely burns
  5. Dark brown
    - Very rarely burns
  6. Black
    - Does not burn
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Dermatology
- Family histories

A

Dermatology FHx

  1. Skin disease
  2. Atopy
  3. Autoimmune
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Dermatology
- SHx

A

Dermatology SHx

  1. Occupation
    - Sun exposure
    - Contactants
  2. Improvement when away from work
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Dermatology History
- Drug Hx

A

Dermatology DHx

  1. Regular/recent
  2. Systemic/topical
    - Where
    - How much
    - How long
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Dermatology exam

  • SCAM
A

Dermatology SCAM

S - ite
C - colour
A - ssociated changes
M - orphology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Dermatology
- ABCD

A

Dermatology ABCD

A - ssymetry
B - order
C - olour
D - iameter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Atopic Eczema
- Mx

A

Atopic Eczema - Mx

  1. Irritiant Avoidance
    - Soap/detergents, oveheating/rough clothing
    - Infections, pets, pollen, HDM, stress
  2. Emollients
  3. Topical CSTs
    - Daily
    - Face more mild than body
  4. Antihistamines
    - Pruritus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Suspected Melanoma
- Mx

A

Suspected Melanoma

  • Refer on urgent pathway if:
  1. > 3 points
    - 2 points for major: Size/shape/colour change irregularity
    - 1 point for minor: 7mm/inflammation/oozing/sensation change
  2. Suspected nodular melanoma
  3. Dermoscopy is suggestive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Eczema
- Emmolients

  1. Role
  2. Ingredients
  3. Escalation
A

Emmolients

  1. Medical moisturisers
  2. Fats
    - eg. paraffin
    - and water
  3. Additional antimicrobials
  4. Rehydrates skin
    - re-establishes lipid layer
  5. Lotions-> creams -> ointments
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Eczema
- Emolient use

  1. Dosing
  2. Timing
  3. Dispenser
  4. Risks
  5. Terminating
A

Eczema
- Emolient use

  1. Liberal and frequent
    - BD-QDS
  2. After washing to trap moisture
  3. Pump dispensers
    - Avoid bacteria
  4. Paraffin is flammable
  5. Continue after flare
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Eczema steroids
- Escalation

A

Eczema steroids
- Escalataion

  1. Hydrocortisone
  2. Euvomate
    - Clobetasone butyrate
  3. Betnovate
    - Betamethasone valerate
  4. Dermovate
    - Clobetalsol propionate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Eczema
- Sleep disturbance Mx

A

Eczema Sleep disturbance

  • Antihistamines
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Topical steroids

  1. Local SEs
A

Topical CSTs
- Local SEs

  1. Skin atrophy
  2. Telangiectasia
  3. Striae
  4. Acne
  5. Perioral dermatitis
  6. Allergic contact dermatitis
  7. Exacerbate skin infections
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Topical steroids
- Systemic SEs (PO)

A

Steroid systemic SEs

  1. Cushing’s
  2. Immunosuppression
  3. HTN
  4. DM
  5. OP
  6. Cataracts
  7. Steroid-induced psychosis
  8. Fluid retention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Topical steroids
- Patient-friendly dosing

A

Topical steroids
- Patient-friendly dosing

  1. Finger Tip Units
  2. Eg.
    - Face and neck - 2.5 FTUs
    - Arm -3FTUs
  • Leg - 6FTUs
  • Trunk - 7FTUs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Eczema
- Maintenance mx

A

Eczema
- Maintenance mx

  1. Emollients
  2. Low-potency steroids
  3. Dressings
    - Dry/medicated bandages
    - Wet wraps (not for wet eczema)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Eczema
- Frequent flare-up management

A

Eczema
- Frequent flare-up management

  1. Check compliance
  2. Steroid weekend regime
    - Weekly 2/7 of potent steroids
  3. Consider alternatives
    - eg. Protopic (Tacrolimus)
  4. Skin swab/nasal swabs
    - Bactroban if staph positive
  5. Consider allergic dermatitis
  6. Immunomoddulators
    - eg. Protopic (Tacrolimus)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Topical Calcineurin Inhibitors

  • 2 Drugs
  • 2 Uses
  • 3 SEs
A

Topical Calcineurin Inhibitors

  • Examples
    1. Protopic (tacrolimus ointment)
    2. Elidel (pimecrolimus cream)
  • Use
    1. Atopic dermatitis
    2. Preventing flare-ups
  • SEs
    1. Local skin irritation
    2. Area risk of HSV
    3. Worsens acute infections
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Scalp eczema
- Tx

A

Scalp eczema tx

  1. Tar-based shampoo
    - <18mo, emollient bath oil
  2. Topical steroids (water-based scalp application)
    - Betacap
    - Sebco ointment for scale removal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Dermatology
- Use of methotrexate

  1. Uses
  2. Dosing
  3. SEs
A

Dermatology - methotrexate

  • 2 Uses
    1. Psorisis
    2. Eczema
  • Dosing
    1. PO/SC
    2. Folic acid - separate day!
  • SEs
    1. GI upset
    2. Mouth ulcers
  1. Fatigue/anaemia
  2. Liver
  3. Lung fibrosis
  4. BM suppression - screen for infections/live vaccines
  5. Teratogenic - contraception (male and female!)
  6. Interactions
    - Trimethoprim
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Methotrexate

  1. Initiating
  2. Monitoring
A

Methotrexate

  • Initiating
    1. Pregnancy test
    2. FBC
    3. U&E/LFT
  • Monitoring (2-3 months)
  1. FBC
  2. U&E
  3. LFTs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Azathioprine
- Dermatology

  1. Uses
  2. SEs
  3. Screening/monitoring
A

Azathioprine
- Dermatology

  • Uses
    1. Atopic eczema
  • SEs
    1. BM suppression
    2. Allergic reaction
    3. GI upset
    4. Prolonged use
  • Skin cancer
  • Lymphoma
  • Screening/monitoring
    1. TPMT test
    2. Monitor FBC,LFT,U&E
    3. Avoid live vaccines
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Ciclosporin
- Dermatology

  1. Uses
  2. SEs
  3. Monitoring
A

Ciclosporin
- Dermatology

  • Uses
    1.Psoriasis
    2. Atopic eczema
  • SEs
    1. Gingival hyperplasia
    2. GI Upset
    3. Fatigue
  1. Tremor
  2. Excessive hair growth
  • Monitoring
    1. No live vaccines
    2. No prgenancies
    3. No breast feeding
    4. Drug interactions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Comedonal acne
- First line
- SEs

A

Comedonal acne
- Mx

1st line — Topical retinoid

  1. Adapelene
  2. Isotretinoin
    + Benzoyl peroxide
  3. Avoid in pregnancy
  4. Dries skin and irritates
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Papular/pustular acne
- Mx

A

Papular/pustular acne
- Mx

Combination

  1. Epiduo
    (adapelene +BPO)
  2. Duac
    (clindamycin +BPO)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Refractive acne
- Mx

A

Refractive acne Mx

  • Systemic ABx
  1. Tetracycline
    - Not in children or pregnancy
  2. Macrolides
    - Erythromycin/clarythromycin
  3. Trimethoprim
    - Used in young children
    - Some bacterial resistance
  4. Primary care
    - Stop oral ABx after 3mo
    - See dermatologit
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Female: Moderate-severe acne
- GP Mx
- ADRs

A

Female acne - moderate-severe

  1. Dianette
    - Cyproterone acetate
    + ethinyloestradiol
  2. Increased risk of VTE
    - CI’d in FHx of VTE
    - CI’d in past VTE
    - Not indicated as sole OCP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Acne
- Referal criteria

A

Acne
- Referal criteria

  1. Severe acne
  2. Moderate acne
    - Partially responsive
    - Scarring
    - Hyperpigmentation
  3. Psychological symptoms
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Retinoids
- ADRs

A

Retinoids
- ADRs

  1. Dry skin/dry lips/ dry eyes
  2. Fragile skin
    - Avoid waxing
  3. Increased infection risk
  4. Slower healing
  5. Increased sun sensitivity
  6. LFT derangement
    - Cholesterol and tri-glycerides
  7. Myalgia/arthralgia
  8. Depression/DSH/Suicide
  9. Teratogenic
    - Acitretin (3 years)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Psoriasis
- Mx

A

Psoriasis Mx

  • Consider co-morbidities
    1. Psoriatic arthritis
  • Rheumatology referral
    2. CVD
  • Drugs
    1. Emollients
  • Reduce scale
    2. Flare-ups
  • Vitamin D
    eg. Dovobet/Enstilar foam 8-12/52
  • Moderate steroid eg. Eumovate 1-2/52
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Psoriasis
- Vitamin D analogues

  1. Names
  2. Role
  3. SEs
A

Psoriasis Vitamin D analogues

  • Drugs
    1. Calcipotriol
    2. Tacalitol
    3. Calcitriol
  • Role
    1. Regulate immune system
    2. Slow overgrowth
  • SEs
    1. Irritate sensative areas
    2. Hypercalcaemia
    3. Not recommended during preganancy.breast feeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Psoriasis
- 2nd line referral

A

Psoriasis second line

  1. Phototherapy
  2. Acitretionin
  3. Methotrexate
  4. Ciclosporin
  5. PD4 inhibitor
    - Apremilast
  6. Dimethyl fumerate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Psoriasis
- Phototherapy

  1. Timing
  2. Types
A

Psoriasis Phototherapy

  • Timing
    1. Twice weekly
    2. 15-30 treatments
  • Types
    1. Narrowband UVB
  • Severe psoriasis and eczema
  1. PUVA (deeper reaching)
    - Psorelan +UVA
    - Psoriasis, vitiligo, cutaneous T-cell lymphoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Dermatology Phototherapy
- ADRs

A

Dermatology Phototherapy
- ADRs

  1. Redness/discomfort
  2. Dry and itchy
  3. Folliculitis
  4. Poly-morphic light erruption (rash)
  5. Cold sores
  6. Worsening of skin disease
  7. Nausea
    - From PUVA psoralen
  8. Premature aging/skin cancer
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Dermatology
- Apremilast

  1. Mechanism
  2. ADRs
A

Dermatology - Apremilast

  • Mechanism
    1. PDE4 i (Phosophodiesterase 4 i)
    2. Skin inflammatory processes
  • ADRs
    1. GI upset
    2. Headache/insomnia
    3. Tiredness/muscle pain
    4. Resp infections
  1. Avoid pregnancy/live vaccines
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Dermatology
- Dimethyl fumerate (fumaric acid)

  1. Mechanism
  2. SEs
A

Dimethyl fumerate (fumaric acid)

  • Mechanism
    1. FAE acts on immune system
  • SEs
  1. GI upset
  2. Headache
  3. Flushing
  4. Monitor LFT, U&E, urine dip, FBC
    - Leukoencephalopathy
  5. Avoid pregnancy/breastfeeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Psoriasis
- Biologics

  1. Use
  2. Names
  3. SEs
A

Psoriasis Biologics

-Use
1. Methotrexate and ciclosporin no effect/tolerated
2. Large impact disease

  • Drugs
    1. Ustekinumab
    2. Adalimumab
    3. Secukinumab
  1. Infliximab
  • SEs
  1. TB/Hep BC/HIV/ VZV screen
  2. No live vaccines
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Scalp psoriasis
- Mx

A

Scalp psoriasis
- Mx

  1. Potent CSTs
    - Betacap 4 weeks
  2. Descaling
    - Diprosalic
  3. Potent CTs with Calcipotriol
    - Dovobet 4 weeks
  4. Very potent CST
    - Etrivex shampoo 4 weeks
    - Sebco scalp ointment OD/BD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Venous ulcer
1. Sx
2. Mx

A

Venous ulcer

  • Sx
    1. Well defined, below knee
    2. Brown edges, granulation tissue
    3. Itchy
  • Mx
    1. Compression stockings
  • Check ABPI with doppler
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Nail dystrophy
- Causes

A

Nail dystrophy
- Causes

  1. Melanoma
  2. Trauma
  3. Fungal infection
  4. Psoriasis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Melanoma
- Prognostication

A

Melanoma
- Prognostication

  • Breslow thickness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Tinea pedis
- common organism
- Treatment

A

Tinea pedis

  • common organism
    Trichophyton rubrum
  • Treatment
    Fluconazole
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Perioral dermatitis
- Distribution
- Treatment

A

Perioral dermatitis

  • Distribution
    1. Tiny blisters
  • red, itchy
  • tingle, burn
    2. Muzzle area
    (Triggered by steroids)
  • Treatment
    1. Stop using cleanses/steroids
    2. Non steroids
  • Elidel cream (Pimecrolimus)
  • Minocycline
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

SCC
- Poor prognosis sites

A

SCC
- Poor prognosis sites

  1. Lips
  2. Ears
  3. Eyes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Bullous pemphigoid
- Blisters
- Treatment

A

Bullous pemphigoid

  • Blisters
    Tense
    Some empty
  • Treatment
    0. Autoimmune condition
    1. Topical Steroids (Dermovate)
    2. Doxycycline
    3. Prednisolone (0.5mg/kg)
  • until no new blisters
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

High dose steroids
- protection

A

High dose steroids
- protection

  1. PPI
  2. Steroid card
    - COVID warning
  3. Bone protection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Psoriasis
- appearance
- treatment

A

Psoriasis

  • appearance
    0. Demarcated scaly plaques
    1. Extensors
    2. Ears
    3. Scalp
    4. Natal cleft
    5. Nail pitting
  • treatment
    1. Retinoids
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Lesions
- 5 Ss

A

Lesions
- 6 Ss

1 Site
2 Shape
3 Size

4 Shade
5 Surface
6 Surrounding skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Acne
- Combination gels

A

Acne
- Combination gels

  1. Duac
    - BP
    - Clindamycin
  2. Epiduo
    - BP
    - Adapalene (retinoid)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Roaccutane
- ADRs

A

Roaccutane (Isotretinoin)
- ADRs

  1. Dry eyes, skin, nose
    - Thin and breakable
  2. Sore throat/mouth
  3. Headaches
  4. Teratogenic
    - COCP
  5. Low mood
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Eczema
- Mx ladder

A

Eczema
- Mx ladder

  1. Emollients
  2. Topical csts
    (mild, mod, potent)
  3. Topical calc. i.
    - Tacrolimus/pimecrolimus
  4. Bandages
  5. Phototherapy
  6. Oral CSTs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Psoriasis
- Common Types

A

Psoriasis
- Types

  1. Plaque
    - psoriasis vulgaris
  2. Scalp psoriasis
  3. Nail psoriasis
  4. Guttate psoriasis
    - <1cm on trunk, limbs scalp
    - Post strep
  5. Inverse psoriasis
    - flexural
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Psoriasis
- Four less common types

A

Psoriasis
- Four less common types

  1. Pustular psoriasis
  2. Generalised pustular psoriasis
    - Von Zumbusch psoriasis
  3. Palmoplantar pustulosis
  4. Erythrodermic psoriasis
    - Nearly all the skin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Lentigo maligna
- Features
- Tx

A

Lentigo maligna

  • Features
    1. Slow growing brown patch
    2. Evolves into melanoma
    3. Commonly on the face
    4. Commonly on older people
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Nodular melanoma
- Mx

A

Nodular melanoma
- Mx

Stage 0

  • Consider Imiquimod
  • 0.5cm margin excision
  • Repeat bipsy

Stage 1
- 2cm margin excision (1 if disfiguring)
Stage 2
- 2cm margin excision

Stage 3
- Excision
- Adjuvant chemo
- No adjuvant radio unless risk outweighs harms

Stage 4
- MDT
- Surgery/ablation
- Brain surgery/radio
- Consider chemo/immnotherapy
(Nivolumab/ipilimumab)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Acral melanoma
- Features

A

Acral melanoma
- Features

  1. Palms, soles, fingernails/toenails
  2. Common in darker skin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Sub-ungal haematoma
- Features
- Mx

A

Sub-ungal haematoma

  • Features
    1. Pseudo hutchinson’s sign
    2. Subungal blood
  • Mx
    1. Follow up
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Benign longitudinal melanonychia
- Features
- Mx

A

Benign longitudinal melanonychia

  • Features
    1. Thin
    2. Multiple
  • Mx
    1. Biopsy to r/o melanoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Classic seborrheic keratoses
- Features
- Mx

A

Classic seborrheic keratoses

  • Features
    1. Brown ‘warty’ appearance
  • comedo-like openings
    2. Milea-like cysts
    3. Older person
    4. Multiple similar lesions
    5. Rough to touch
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Non-melanoma skin cancer
- Two pre-malignant conditions

A

Non-melanoma skin cancer
- Pre-malignant conditions

  1. Actinic keratosis
  2. Bowen’s disease
    - Pink patch
    - Full thickness dysplasia
    - In situ SCC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

BCC
- Appearance
- Growth
- Ex

A

BCC
- Appearance
1. ‘Rodent ulcer’
2. Rolled pearly margin
- Translucent stroma production
- Well defined blood vessels
3. Morphoeic BCC
- indistinct edges
4. Superficial BCC
- Pink patch
- Similar to Bowen’s disease
5. Pigmented BCC
- Grey ‘bean-like’ structure
6. Slow growing

  • Growth
    1. Destruction
    2. Can wrap around nerve
  • death from brain metastasis
  • Ex
    1. Good lighting and remove crust
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

MOHS
- Sites
- Process

A

MOHS

  • Sites
    1. Sensitive
    2. Narrow margin
  • Process
    1. LA
    2. Horizonal cut
    3. Frozen section
    4. Margins - peripheral and deep
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Picker’s Nodule
- Features
- Mx

A

Picker’s Nodule

  • Features
  1. Intensely itchy
  • Mx
    1. Psychiatry
    2.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Dermatofibroma
- Features
- Mx

A

Dermatofibroma

  • Features
    1. May mimic bcc, scc, melanoma
    2. Firm nodules
    3. Dimple sign
  • Pinch - and see dimple in the middle
  • Mx
    1. Observe
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

SCC
- Features

A

SCC

  • Features
    1. 1/5 Type 1,2 skin
  1. Can be painful
  2. Keratotic nodule
  3. Fleshy - can be ulcerated
  4. Rapidly growing
  5. Sun-exposed locations
    - Ear helix
    - Hand
    - Actinic keratosis
66
Q

arSCC
- Mimics

A

SCC
- Mimics (biopsy them)

  1. Viral warts
    - inflamed squamous papillomas
    - Keratin horn
    - Painless and pruritis
  2. Regressing keratocanthoma
    - Painless
    - Ulcerated
    - Crateriform
  3. Sebhorric keratosis
    - Large
    - Traumatised
    - Inflammed
  4. Lymphoedema nodule
    - Granulation tissue
    - Fluid
  5. Giant comedone
67
Q

Skin cancer
- Topical options

A

Skin cancer
- Topical options

  1. 5FU (Efudix)
    - AK, Bowen’s disease
  2. Diclofenac
    - AK
  3. Imiquimod (Aldara)
    - Superficial BCC
  4. Retinoids
68
Q

Surgical excision options

A

Surgical excision options

  1. Standard wide excision
    - pre-determined margins
  2. MOHS
    - Micrographic excision
    - Layer by layer with staged mapping
69
Q

Skin cancer
- Non-surgical procedures

A

Skin cancer
- Non-surgical procedures

  1. Photodynamic therapy (PDT)
    - Photosensitiser attaches to dysplastic cells
    - Shine a light
    - Photosensitiser destroys cells
  2. Cryotherapy
    - Superficial lesions
    - SK to AK, Bowen’s and Superficial BCC
70
Q

Skin cancer
- Radiotherapy uses

A

Skin cancer
- Radiotherapy uses

  1. Older persons
    - SCC (good response)
    - BCC (less good response)
71
Q

Metastatic skin cancer
- Systemic treatment

A

Metastatic skin cancer
- Systemic treatment

  1. Immune therapy
72
Q

Sun behaviour
- Incl sun screen

A

Sun behaviour
- Incl sun screen

  1. Avoid sun
  2. Sunscreen
    - 15-30 minutes before exposure
    - 2-hourly reapplication
    - 30mls + for adults
  3. SPF
    - 4 - 75% blockage
    - 15 - 93% blockage
    - 30 - 96% blockage
73
Q

Actinic keratosis
- 5-FU/Imiquimod treatment progress

A

Actinic keratosis
- 5-FU/Imiquimod treatment progress

  1. Application
  2. 1-2 weeks later eruption
  3. 6-7 weeks later recovery
74
Q

Cryosurgery
- Process

A

Cryosurgery
- Process

  1. Liquid nitrogen
    (-196ºC)
  2. Ice crystals form
75
Q

Skin cancer
- Surgical principles

A

Skin cancer
- Surgical principles

  1. Remove all cancer
    - Prevent metastatic spread
  2. No biopsies
  3. Wide-local excision
    - 2mm margin where possible
    - fully excised
    - 3-1 ratio for elipse
    - scar longer than patient expects
76
Q

Pre-determined margins

  1. Melanoma
  2. SCC
  3. BCC
A

Pre-determined margins

  • Melanoma
    1. In situ (5mm)
    2. <1mm thickness (1cm)
    3. >2mm thickness (2cm)
  • SCC
    4. 4-8mm
  • BCC
    5. 3-5mm
  • Suspicious pigmented lesion
    6. 2mm
77
Q

Superficial spreading malignant melanoma
- Features
- Mx

A

Superficial spreading malignant melanoma

  • Features
  • Mx
78
Q

Skin cancers
- 1 Key fact for diagnosis
- 2 Powerful risk factors

A

Skin cancers

1 Key fact for diagnosis
- Onset and rate of growth

2 RFs
- Sun exposure
- Genetics

79
Q

Cancer layer origins
- BCC
- SCC
- Melanoma

A

Cancer layer origins

  • BCC
    1. Basal epidermis
  • SCC
  1. Epidermal squamous
  • Melanoma
    3. Epidermis
80
Q

Skin cancer
- Proportions and referrals

  1. 2WW
  2. Routine
A

Skin cancer
- Proportions and referrals

  1. 2WW
    - 10% melanoma
    - 30% SCC
  2. Routine
    - 60% BCC
81
Q

Melanoma
- Breslow and prognosis

A

Melanoma
- Breslow and prognosis

1mm - 100% 5YS
4mm - 60% 5YS

82
Q

BCC
- Demoscopy signs

A

BCC
- Demoscopy signs

  1. Telangiectasia
    - Tree-like trunky red vessels
83
Q

Basal cell c
- Subtypes

A

Basal cell c
- Subtypes

  1. Superficial spreading BCC
    - Patch
  2. Nodular BCC
  3. Infiltrative/Scar-like BCC
84
Q

BCC Treatments

  • Non-surgical
  • Surgical
A

BCC Treatments

  • Non-surgical
    1. Cryotherapy
  • Superficial BCC
  • 99% 5 year cure
  • Liquid nitrogen
  • 20s, 30s gap, 20s
  1. Creams
    - 5FU
    - Imiquimod
  2. PDT
    - Sensitising cream
    - Red light
  3. Radiotherapy
  • Surgical
  1. Curettage and cautery (24%)
    - 90% cure
  2. Excision (58%)
    - 4-5mm margin
    - <2% recurrence
85
Q

SCC
- Dermoscopy

A

SCC
- Dermoscopy

  1. Keratin Patch
86
Q

SCC
- Followup

  1. Low risk
  2. High risk
A

SCC
- Followup

  1. Low risk
  2. High risk
    - 4-6 mo
    - Lymphadenopathy
87
Q

Melanoma
- most common age groups

A

Melanoma
- most common age groups

  • 38% 45-65
  • 20% 65-75
88
Q

Benign lesions
- Features

A

Benign lesions
- Features

  • Symmetry good
  • Border regular
  • Colour uniform
  • Diameter (vague) >6mm
  • Evolution
89
Q

Melanoma
- Dermoscopy

A

Melanoma
- Dermoscopy

  1. Dysplastic colour
90
Q

Melanoma
- Acral
- Lentigo

A

Melanoma

  • Acral
    1. Palms/soles
    2. Eg. Sub ungual
  • Lentigo
    1. Face/sun touched
91
Q

Melanoma
- Margin paradox

A

Melanoma
- Margin paradox

  1. 2mm
  2. Further surgery with lymph nodes
    - eg. 2cm
92
Q

Melanoma
- Immunotherapies

A

Melanoma
- Immunotherapies

  1. IL2
    - interferon alpha
  2. Nivolumab
    Imatinib
93
Q

Melanoma
- Followup

A

Melanoma
- Followup

  1. Superficial
    - 1 year

2.

94
Q

Comedone
- Definition

A

Comedone
- Definition

  1. Plug in sebaceous follicle
  2. Contains
    - sebum
    - bacteria
    - cellular debris
  3. Open (blackhead)
    - Closed (whitehead)
95
Q

Dermatology
- Distributions

A

Dermatology
- Distributions

  1. Generalised
    - All over the body
  2. Widespread
  3. Localised
    - One area only
  4. Flexural/extensor
  5. Pressure areas
    - sacrum, buttocks
    - ankles, heels
  6. Dermatomal/photosensative
96
Q

Dermatology
- Koebner phenomenon

A

Dermatology
- Koebner phenomenon

  1. Site of trauma
  2. Linear erruption
97
Q

Lesions
1. Target
eg.
2. Annular
eg.

A

Lesions

  1. Target
    - Concentric circles
    eg. erythema multiforme (immune eg. HSV)
  2. Annular
    - Circle/ring
    eg. tinea corporis (ringworm)
98
Q

Lesions

  • Discoid/nummular
    1. Description
    example
A
  • Discoid/nummular
  1. Round lesion/coin-shaped
  2. Discoid eczema
  3. Hypopigmentation in SLE
99
Q

Erythema

  • Pathophysiology
A

Erythema
- Pathophysiology

  1. Inflammation
  2. Vasodilation
100
Q

Purpura

  1. Pathophysiology
  2. Types
A

Purpura

  1. Pathophysiology
    - bleeding into skin
    - bleeding into mucous membrane
    - non-blanching
  2. Types
    - petechiae
    - ecchymoses
101
Q

Hypo-pigmentation
- Definition
- Example

Vitiligo
- Definition
- Example

A

Hypo-pigmentation

  • Definition
    1. Paler skin areas
  • Example
    1. Pityriasis versicolor (superficial fungus)

Vitiligo
- Definition
1. Absence of melanin
- Example
2. Vitiligo (loss of melanocytes)

102
Q

Hyper-pigmentation

  • Broad Differentials
A

Hyper-pigmentation
- Broad Differentials

  1. Post-inflammatory
  2. Melasma
  3. Naevi
103
Q

Melasma
- Pres
- Tx

A

Melasma

  • Pres
    1. Hormonal
    2. UV
    3. Malar region of darker skin
  • Tx
    1. Retinoids (bleaching)
    2. Bleaching/chemical peels
    3. Laser/light therapy
    4. Sun protection
104
Q
  1. Macule
    - definition
    - example
  2. Patch
    - definition
    - example
A
  1. Macule
    - Flat area of altered colour
    - eg Freckles
  2. Patch
    - Larger flat area of altered colour or texture
    - eg vascular malformation (naevus flammeus/PW stain)
105
Q

Raised lesions

  • Papule
  • Nodule
  • Plaque

+examples

A

Raised lesions

  1. Papule
    - Solid raised lesion
    + xanthomata
  2. Nodule
    - Solid raised lesion with deeper component
    + Pyogenic granuloma (telangiectaticum)
  3. Plaque
    - Palpable scaling raised lesion
    + Psoriasis
106
Q
  1. Vesicle
  2. Bulla
  3. Pustule
  4. Abscess
A
  1. Vesicle
    - Raised clear filled lesion
    + Acute hand eczema
  2. Bulla
    - Raised, clear filled lesion
    + Insect bite reaction
  3. Pustule
    - Pus-filled lesion
    + Acne
  4. Abscess
    - Localised accumulation of pus
    + Peri-ungal abscess (paronychia)
107
Q
  1. Boil/furuncle
  2. Carbuncle
A
  1. Boil/furuncle
    - Around/within follicle
    - Staph infection
  2. Carbuncle
    - Adjacent hair follicles
    - Staph infection
108
Q
  1. Excoriation
  2. Lichenification
A
  1. Excoriation
    - Trauma to epidermis
    +Eczema
  2. Lichenification
    - Roughening of skin with markings
    + Chronic eczema
109
Q
  1. Scales
  2. Crust
A
  1. Scales
    - Flakes of stratum corneum
    + Psoriasis (silvery scales)
  2. Crust
    - Rough surface through epidermis
    - Serum, blood, bacteria, debris
    + impetigo
110
Q
  1. Ulcer
  2. Fissure
A
  1. Ulcer
    - Loss of epidermis and dermis
    - Heals with scar
  2. Fissure
    - Epidermal crack
    + Dryness/eczema
111
Q
  1. Scar
  2. Striae
A
  1. Scar
    - New fibrous tissue
    - post-healing
    + keloid scar
  2. Striae
    - Linear area
    - Purple -> Pink -> White
    - Scar-like
    +Steroid use/ growth /pregnancy
112
Q

Scar
- Three classifications

A

Scar
- Three classifications

  1. Atrophic
    - thinning
  2. Hypertrophic
    - within wound boundary
  3. Keloidal
    - beyond wound boundary
113
Q

Hirsuitism vs Hypertrichosis

A

Hirsuitism vs Hypertrichosis

  1. Androgen dependent hair-growth
    - in a female
  2. Non-androgen dependent
    - eg. pigmented naevi
114
Q

Nails

  1. Clubbing
  2. Koilonychia
  3. Onycholysis
  4. Pitting
A

Nails

  1. Clubbing
    - Loss of angle
    - Posterior nail fold and nail plate
  2. Koilonychia
    - Spoon-shaped depression
  3. Onycholysis
    - Separation of distal end from nail bed
    - Trauma, psoriasis, fungal, hyperthyroid
  4. Pitting
    - Punctate depressions
    - Psoriasis, eczema, alopecia
115
Q

Skin
- Skin appendages

A

Skin
- Skin appendages

  1. Hair
  2. Nails
  3. Sebaceous glands
  4. Sweat glands
116
Q

Skin
- Four cell types
- Cell functions

A

Skin cells

  1. Keratinocytes
    - Keratin barrier production
  2. Langerhans’
    - Antigens and T-Cell activation
  3. Melanocytes
    - Melanin UV protection
  4. Merkel
    - Nerve endings for sensation
117
Q

Epidermis
- Layers

A

Epidermis
- Layers

  1. Basale
    - Dividing cells
  2. Spinosum
    - Differentiating cells
  3. Granulosum
    - Keratohyalin + lipid
  4. Corneum
    - Keratin
118
Q

Skin layers
- Sole and Palm

A

Skin layers
- Sole and Palm

  1. Lucidum
    - Pale, compact keratin
  2. Beneath Corneum
119
Q

Dermis
- Main cell type
- Main proteins

A

Dermis
- Main cell type
1. Fibroblasts
2. Immune and appendages
3. Connective tissues

  • Main proteins
    1. Collagen (mainly)
    2. Elastin
    3. Glycosaminoglycans
120
Q

Hair
- Three types
- Three growth cycles

A

Hair
- Three types
1. Lanugo (fetus)
2. Vellus (fine short)
3. Terminal (coarse long)

  • Three growth cycles
    1. Anagen (long; growth)
    2. Catagen (short; regression)
    3. Telogen (Resting; shedding)
121
Q

Sebaceous glands

  1. Secretion
  2. Stimulation
  3. Pathologies
A

Sebaceous glands

  • Secretion
    1. Sebum
    2. Pilosebaceous unit
  • Stimulation
    1. Dihydrotestosterone from androgens
    2. Starts at puberty
  • Pathologies
    1. Sebum and bacterial colonisation
    2. Gland hyperplasia
122
Q

Sweat glands

  1. Stimulation
  2. Types
  3. Pathologies
A

Sweat glands

  • Stimulation
    1. Sympathetic nervous system
  • Types
    1. Eccrine
  • Universal
    2. Apocrine
  • Puberty onwards
  • Axillae, areolae, genitalia, anus
  • Bacterial action produces body odour
  • Pathologies
    1. Apocrine inflammation/infection
  • Hidradenitis suppurativa
  1. Eccrine overactivity
    - Hyperhidrosis
123
Q

Wound healing
- Stages

A

Wound healing
- Stages

  1. Haemostasis
    - Vasoconstriction
  2. Inflammation
    - Vasodilation
  3. Proliferation
    - Granulation tissue
    - Angio-genesis
    - Re-epithelialisation
  4. Remodelling
    - Collagen fibre re-organisation
    - Scar maturation
124
Q

Erythema nodosum
- Presentation

A

Erythema nodosum
- Presentation

  • Hypersensitivity Response
  1. Shins, most commonly
  2. Discrete tender nodules
    - May become confluent
  3. Lesions appear for two weeks
    - Bruise-like discolouration on resolution
125
Q

Erythema nodosum
- Causes

  1. Infection
  2. Inflammation
A

Erythema nodosum
- Hypersensitivity Response

  • Infection
    1. Group A Strep
    2. TB
    3. Chlamydia
    4. Leprosy
  • Inflammation
    1. Pregnancy
    2. Malignancy
    3. IBD
    4. Sarcoidosis
126
Q

Acute skin management

  1. Principles for:
    - Erythema multiforme
    - Stevens-Johnson Syndrome
    - Toxic Epidermal Necrolysis
  2. Complications
A
  1. Erythema multiforme
  2. Stevens-Johnson Syndrome
  3. Toxic Epidermal Necrolysis
  • Management principles
    1. Early recognition
    2. Full supportive care
  • Complications
    1. Mortality rates 5-12% SJS, >30% TEN
    2. Sepsis
    3. Electrolyte imbalance
    4. Multi-system organ failure
127
Q

Acute Skin Conditions
- Presentations

  1. EM
  2. SJS
  3. TEN
A

Acute Skin Pathologies

  1. Erythema multiforme
    - Often unknown/Herpes Simplex/Drugs
    - Acute self-limiting
    - Mucosa limited to one surface only
  2. SJS
    - Muco-cutaneous necrosis
    - At least two mucosal sites
    - Limited or extensive skin involvement
  3. TEN
    - Drug-induced
    - Extensive skin/mucosal necrosis
    - Systemic toxicity
    - Full thickness epidermal necrosis
    - Sub-epidermal detachment
128
Q

Erythema multiforme
- Presentation

A

Erythema multiforme
- Presentation

  1. Erythematous patches
    - Evolving into target lesions
  2. Often involves both hands
129
Q

SJS
- Early Symptoms

A

SJS
- Early Symptoms

  1. Fever
  2. Flu-like symptoms
  3. Blistering
130
Q

Acute Meningococcaemia
- Rash progression

A

Acute Meningococcaemia
- Rash progression

  1. Blanching maculo-papular rash
  2. Non-blanching purpuric rash
  3. Progression to ecchymoses
    - Haemorrhagic bullae
    - Tissue necrosis
131
Q

Acute meningococcemia
- Close contact prophylaxis

A

Acute meningococcemia
- Close contact prophylaxis

  1. ABx
    - Rifampicin
132
Q

Erythroderma

  • Causes
  • Management
A

Erythroderma

  • Causes
    1. Skin disease (eczema/psoriasis)
    2. Lymphoma
  1. Drugs
    - Sulfonamides
    - Gold
    - Penicillin
    - Allopurinol
    - Captopril
  2. Idiopathic
  • Management
    1. Underlying
  1. Emollients and wet-wipes
  2. Topical steroids
133
Q

Eczema Herpeticum

  • Pathology
  • Presentation
  • Management
A

Eczema Herpeticum
(Kaposi’s varicelliform eruption)

  • Pathology
    1. Atopic eczema or other exacerbation
    2. Herpes simplex cause
  • Presentation
    1. Widespread eruption
    2. Crusted papules
    3. Blisters and erosions
  • Management
    1. Anti-virals (aciclovir)
    2. Antibiotics for 2º infections
134
Q

Necrotising fasciitis
- Causes
- Presentation
- Mx

A

Necrotising fasciitis
- Causes
1. Group A Strep
2. Anaerobes or aerobes
3. RFs - Abdo surgery/co-morbidities

  • Presentation
    1. Severe pain
    2. Erythematous, blistering, necrotic skin
    3. Systemic illness
    4. Surgical crepitus/soft tissue gas
  • Mx
    1. Urgent surgical referral
    2. IV ABx
135
Q

Erysipelas & Cellulitis

  • Pathology
  • Causes
    -Management
A

Erysipelas & Cellulitis

  • Pathology
    1. Dermis and upper sub-cutaneous
  • Erysipelas
    2. Deep sub-cutaneous tissue
  • Cellulitis
  • Causes
    1. Strep pyogenes
    2. Staph a.
    3. RFs: Immunosuppression, wounds, leg ulcers

-Management
1. ABx
- Fluclox/benpen
2. Supportive
- Elevation, dressings, analgesia

136
Q

‘Scalded Skin’ Syndrome (staph)

  • Pathology
  • Presentation
  • Mx
A

‘Scalded Skin’ Syndrome (staph)

  • Pathology
    1. Epidermolytic toxin
    2. Ben-pen resistant staph (coag positive)
  • Presentation
    1. Infancy/childhood
    2. Scald-like skin
  • Large flaccid bullae
  • Perioral crusting
  • Intra-epidermal blistering
    3. Painful lesions
  • Mx
    1. Recovery in 5-7 days
    2. ABx
    eg. Resistant penicillin, erythromycin, cephalosporin
    3. Analgesia
137
Q

Fungal infection
- Site classifications

A

Fungal infection
- Site classifications

  1. Tinea Capitis
    - Scalp ringworm
  2. Tinea Corporis
    - Itchy, circular/annular lesions
  3. Tinea manuum
    - Palmar scaling/dryness
  4. Tinea unguium
    - Nail discolouration, thickening, crumbling
  5. Tinea cruris
    - Groin and natal cleft
  6. Tinea pedis
    - Athlete’s foot
  7. Tinea incognito
    - Tinea treated inappropriately with steroids
  8. Tinea versicolor/Pityriasis
    - Upper trunk scales
    - Malessezia furfur
138
Q

Skin
- Fungal infection mx

A

Skin
- Fungal infection mx

  1. No steroids
    - Tinea incognito
  2. Topical agents
    - terbinafine cream
  3. Oral agents
    - severe/widespread/nail
    - itraconazole
139
Q

Atopic eczema/dermatitis
- Causes

A

Atopic eczema/dermatitis
- Causes

  1. Primary genetic defect
  • skin barrier function
  1. Filaggrin protein loss of function
  2. Exacerbating factors
    - infections
    - allergens
    - sweating, heat, occupation, severe stress
140
Q

Eczema
- Presenting morphology

  1. Acute
  2. Chronic
  3. Papular
A

Eczema morphology

  • Acute
    1. Itchy papules
    2. Vesicles
  • Chronic
    1. Dry scaly patches
    2. Erythematous or grey/brown
    3. Lichenification
  • Papular/follicular
    1. Brown, grey, purple bumps
141
Q

Phototherapy
- dosing units

A

Phototherapy
- dosing units

  1. J/Cm2
142
Q

Pyoderma gangrenosum
- Aetiology
- Pres
- Mx

A

Pyoderma gangrenosum
- Aetiology

  1. Autoimmune
    - Common in RA
  2. Discrete ulcers
    Oedematous, violaceous border
  3. Topical potent steroids
    - betnovate
    - demovate
    - Cyclosporin/cyclophosphamide
143
Q

Punch biopsy

  • Size
  • Examples
A

Punch biopsy

  • Size
    1. <3mm
    2. Full thickness
  • dermis
  • Examples
    1. AK
    2. Pyoderma gangrenosum
144
Q

Cyclosporin
- 5 Hs

A

Cyclosporin
- 5 Hs

  1. Hypertension
  2. Hyperkalaemia
  3. Hypertrichosis
  4. Hair loss
  5. Hypertrophy of gingiva
145
Q

Shave biopsy

  1. Type
  2. Uses
A

Shave biopsy

  1. Type
    - Scooping flat lesions
  2. Uses
    - Flat lesions
146
Q

Incisional biopsy

  • Type
  • Uses
A

Incisional biopsy

  • Type
    1. Deep incision
  • Uses
    1. Vascular structures
    2. Not commonly used
147
Q

Excision biopsy

  1. Type
  2. Uses
A

Excision biopsy

  1. Type
    - Curative eg for skin cancers
  2. Uses
    - SCC
    - BCC
    - Melanoma
148
Q

Breslow Thickness
1. Epidermis
2. Dermis
3. Hypodermis

A

Breslow Thickness

  1. Epidermis
    - No stage (0)
    - In situ melanoma
    ( - Bowen’s disease in SCC)
  2. Dermis
    - Depth of >1mm - 1cm margin
    2-4mm - 1-2cm margin
    4mm - 2 cm margin
  3. Hypodermis
149
Q

Melanoma

  • Staging Ix
  • Mx
A

Melanoma

  • Staging Ix
    1. Staging CT
    2. PET CT
  • Mx
    1. Surgery
    2. Immunotherapy
  1. (Chemo-radio not useful)
150
Q

Rosacea

  • Types
  • Pathology
A

Rosacea

  • Types
  1. Papulopustular
  2. Rhino-phimatous
  • Pathology
    1. Vasodilatation
151
Q

Papulopustular Rosacea

  1. Tx
A

Papulopustular rosacea

  1. Tx
    - Metronidazole
    - Oxytetracicline (3-6 mo)
  • 15-20% Azelaic acid
  • Topical Ivermectin (anti-fungal and anti-biotic)
152
Q

Psoriatic arthritis
- Joint pattern

A

Psoriatic arthritis

  • Joint pattern
    • DIPJ
153
Q

Acne in pregnancy

  1. Retinoids
A

Acne in pregnancy

  1. Oral and topical retinoids are highly teratogenic
    - 6-12 mo course
    - HCG test and LFTs too
  2. High dose salicylates and hydroquinone also not used
  3. Low dose Azelaic acid is allowed
154
Q

Potent topical corticosteroids
- Length of course

A

Potent topical corticosteroids
- Length of course

  1. 8 Weeks max
155
Q

Psoriasis
- Treatment ladder

A

Psoriasis
- Treatment ladder

  1. Topical CST + Top D analogue
    - Enstella
  2. Top Vit D Analogue BD
  3. Top CST + Coal tar OD
  4. Dithranol + Dermatology
    - Black liquid to soak plaques
    - eg. PUVA and PUVB (immunosuppressive)
156
Q

Guttate psoriasis

  • Signs
  • Pathology
A

Guttate psoriasis

  • Signs
    1. Raindrop lesions
    2. Small scaly patches
  • Pathology
    1. Post-viral/strep
157
Q

Pitoriasis rosacea

  • Signs
  • Pathology
A

Pitoriasis rosacea

  • Signs
    1. Fur tree sign
    2. Herald patch
  • Pathology
    1. Post-viral
158
Q

Topical steroid course

  1. Body
  2. Scalp
A

Topical steroid course

  1. Body
    - 8 weeks
  2. Scalp
    - 4 weeks eg. Betnovate
159
Q

Actinic keratosis
- Creams

A

Actinic keratosis
- Immunotherapy Creams
- Skin will get yellow, crusty, and peel

  1. Aldara
    - Contains imiquimod
  2. Effedex
    - Contains 5FU
160
Q

Mohs surgery
- Indications

  • Technique
A

Mohs surgery
- Indications

  1. Delicate places
  2. Visible places
  3. Less disfiguring
  • Technique
    1. Checking under microscope
    2. Returning to surgery
    3. Repeat
161
Q

Which virus is associated with Bowen’s disease?

A

Which virus is associated with Bowen’s disease?

  1. HPV 16&18
162
Q

Signs

  1. Gottron’s
  2. Kernig
  3. Nikolsyiy
  4. Aspitz
  5. Koebner
A

Signs

  1. Gottron’s
    - Dermatomyositis on knuckles
  2. Kernig
    - meningitis
  3. Nikolsyiy
    - Flacid bullous desquamation
  4. Auspitz
    - Pin-point bleeding on psoriasis
  5. Koebner
    - Psoriasis at site of trauma

Year 4 - NSS (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions